What is an ectopic pregnancy?

If a fertilized egg implants outside the uterus, it's called an ectopic pregnancy. About 1 in 50 pregnancies is ectopic. There's no way to transplant an ectopic (literally, "out of place") pregnancy into your uterus, so ending the pregnancy is the only option.

While there are some risk factors, an ectopic pregnancy can happen to anyone. And, because it's potentially dangerous for you, it's important to recognize the early signs and get treatment as soon as possible.

How does it happen?

After conception, the fertilized egg travels down one of your fallopian tubes on its way to your uterus. If the tube is damaged or blocked and fails to propel the egg toward your womb, the egg may become implanted in the tube and continue to develop there.

Because the vast majority of ectopic pregnancies occur in a fallopian tube, they're often called "tubal" pregnancies. Much less often, an egg implants in an ovary, in the cervix, directly in the abdomen, or even in a c-section scar.

It's also possible for a woman to have one embryo normally implanted in her uterus and another implanted in her tube or elsewhere. This is called a heterotopic pregnancy, and it's pretty rare, occurring in only 1 in 4,000 pregnancies.

If an ectopic pregnancy isn't recognized and treated, the embryo could grow until the fallopian tube ruptures, resulting in severe abdominal pain and bleeding. This can cause permanent damage to the tube or loss of the tube, and if it involves very heavy internal bleeding that's not treated promptly, it can even lead to death. That's why early diagnosis, treatment, and follow-up care are so important.

What are the risk factors for ectopic pregnancy?

An ectopic pregnancy can happen to any woman, even if she has no known risk factors. Certain women are at a higher risk than others, though.

One common risk factor is having had any condition or surgery that affected the fallopian tubes, such as:

• Surgery on your fallopian tubes to correct a problem or to reverse a tubal ligation (surgical sterilization). (Your risk may also be higher, though to a much smaller degree, if you've had other pelvic or abdominal surgery.) In the rare case that a woman becomes pregnant after a tubal ligation, the chance that the pregnancy is ectopic is 25 to 50 percent.

• A previous ectopic pregnancy. After one ectopic pregnancy, the chance of having another one is about 1 in 10. If you've had two or more ectopic pregnancies, the chance that you'll have another one is at least 1 in 4.

• An infection in your upper reproductive tract (this is called pelvic inflammatory disease, or PID). PID is often caused by untreated sexually transmitted infections (STIs), such as gonorrhea or chlamydia. It sometimes has no symptoms, so having had either of these STIs also increases your risk for an ectopic pregnancy, even if you don't think you've had PID.

(Having had multiple sexual partners also increases your risk, because this makes it more likely that you've had an STI and PID.)

• Fertility issues. Infertility is often caused by damaged tubes, and if you get pregnant while being treated for infertility, there's a higher than average chance that the pregnancy will be ectopic.

• A mother who took the drug DES while pregnant with you. This may have caused problems, including abnormalities of your fallopian tubes and uterus, which increase your risk for having an ectopic pregnancy. (Note: DES was taken off the market in the United States in 1971 but remained available in some other countries. If you're in your late thirties or older, or your mother lived in another country when she carried you, ask her whether or not she took DES.)

• A gynecological condition called endometriosis may cause scarring that affects your fallopian tubes, increasing your risk of having an ectopic pregnancy.

Women who are 35 years of age or older when they become pregnant are also at an increased risk of ectopic pregnancy. This may be related to a change in how well the tubes work as a woman ages. Or it may be that PID might do increased damage over time in women with infections or women may have repeated episodes of PID.

In the rare instance that you become pregnant with an intrauterine device (IUD) in place, the chance that it's an ectopic pregnancy is higher than average. An IUD doesn't cause an ectopic pregnancy – it's just better at preventing an egg from implanting in your uterus than outside it. Of course, while using an IUD, your overall risk of ectopic pregnancy is much lower than that of the general population. And having used an IUD in the past won't raise your risk for ectopic pregnancy.

You may also be at increased risk of ectopic pregnancy if you smoke. One theory is that smoking may impair the normal functioning of your tubes.

Some studies suggest that if you happen to become pregnant while taking progestin-only hormonal contraceptives the chance that it's ectopic is somewhat increased.

What are the symptoms of an ectopic pregnancy?

Symptoms can appear early in pregnancy and may vary from woman to woman. However, many women have no symptoms at all until the ectopic pregnancy has ruptured.

You may miss a period and begin to experience some of the same symptoms you'd have with a normal pregnancy – like sore breasts, fatigue, and nausea. (If you take an at-home pregnancy test, the result may be positive.) Initially, you may have symptoms such as abdominal tenderness or pain and vaginal bleeding, which may be sporadic and light.

Sometimes an ectopic pregnancy is first suspected when a woman goes to her first prenatal visit and has pain during an abdominal or pelvic exam, or her caregiver detects a mass. Or, it may even be discovered during a first-trimester ultrasound done for another reason.

If you do have any symptoms, it's important to take them seriously. To prevent rupture – a true obstetric emergency – it's critical to get diagnosed and treated as soon as there's even a hint of a problem.

Call your practitioner immediately if you have any of the following symptoms:

Abdominal or pelvic pain or tenderness. It can be sudden, persistent, and severe but may also be mild and intermittent early on. You may find that it gets worse when you're active or while moving your bowels or coughing. You may feel it only on one side, but the pain can be anywhere in your abdomen or pelvis. It may be dull or sharp, and you may also have nausea and vomiting.

Vaginal spotting or bleeding if you've had a positive pregnancy test result. It may look like the start of a light period. The blood may look red or brown, like the color of dried blood, and may be continuous or intermittent, heavy or light.

Shoulder pain. Cramping and bleeding can mean many things, but pain in your shoulder, particularly when you lie down, is a red flag for a ruptured ectopic pregnancy, and it's critical to get medical attention immediately. The cause of the pain is internal bleeding, which irritates nerves that go to your shoulder area.

If a fallopian tube has ruptured, you may also have signs of shock, such as a weak, racing pulse; pale, clammy skin; and dizziness or fainting. In that case, call 911 without delay.

It's also important to seek early care if you think you're pregnant and are in a high-risk group for ectopic pregnancy, particularly if you become pregnant despite having an IUD in place or after having had a tubal ligation, or if you've had other tubal surgery, a previous ectopic pregnancy, or PID.

If you're receiving fertility treatments and become pregnant, your healthcare provider will carefully monitor your pregnancy, but be sure to alert her immediately to any ectopic pregnancy symptoms you think you may have.

How is it diagnosed?

Ectopic pregnancy can be tricky to diagnose. If your symptoms suggest this type of pregnancy, your caregiver will begin by doing an ultrasound together with a blood test to try to confirm the diagnosis:

The blood test is to check your level of the pregnancy hormone human chorionic gonadotropin (hCG). If it's high enough to suggest pregnancy, but not as high as it should be at your stage, the pregnancy may be ectopic. If you're not in pain and there's still some question about the diagnosis, the test may be repeated in two or three days. If your hCG level doesn't increase as it's supposed to, this probably indicates either an ectopic pregnancy or an increased risk for miscarriage of a normally implanted pregnancy (in the uterus).

During the ultrasound, the sonographer will look closely at your tubes and uterus. If the sonographer can see an embryo in the fallopian tube, you definitely have an ectopic pregnancy. But in most cases, the embryo will have died early in the process and be too small for the sonographer to find. Instead, she may notice that a fallopian tube is swollen and may see blood clots as well as tissue left from the embryo.

The sonographer will also look to see if there is a pregnancy in the uterus. If a pregnancy test is positive but the embryo (or evidence of an embryo) can't be found, you may have an ectopic pregnancy – but it's also possible that the pregnancy is still in the very early stages or that you have miscarried. As long as you're not in pain, your caregiver will continue to monitor you very closely through hormone tests and ultrasounds until she can confirm the diagnosis or your symptoms become more severe.

If it remains unclear whether or not you've miscarried or have an ectopic pregnancy, your caregiver may do a surgical procedure called dilation and curettage (D&C) to check for and remove any tissue in your uterus. Or she may examine your tubes by using laparoscopic surgery, where a tiny camera is inserted into your abdomen through a small incision.

How is it treated?

That depends on how clear the diagnosis is, how big the embryo is, and what techniques are available.

If the pregnancy is clearly ectopic and the embryo is still relatively small, you may be given the drug methotrexate. The drug is injected into a muscle and reaches the embryo through your bloodstream, where it ends the pregnancy by stopping the cells of the placenta from growing. (Over time, the tiny embryo is reabsorbed into your body.)

As the drug begins to work you may have some abdominal pain or cramps and possibly nausea, vomiting, and diarrhea.

You'll need to avoid alcohol, nonsteroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen, aspirin, and naproxen – and any multivitamins or supplements that contain folic acid. You also need to avoid sex, all vigorous activity, and sunlight.

Afterward, you'll need to get a series of blood tests to check your hCG levels to make sure that the ectopic pregnancy has been completely removed. This testing will continue until the levels reach zero, which usually takes a few weeks.

If you experience any signs of rupture (such as severe abdominal pain, shoulder pain, or heavy bleeding), or signs of shock (such as a weak, racing pulse; pale, clammy skin; and dizziness or fainting) during this process, call 911 right away.

If you're too far along for methotrexate to be used, you're in severe pain or bleeding internally, or you're breastfeeding or have certain health conditions that make the medication a bad choice, you'll need surgery. (If you're bleeding heavily, you may need a blood transfusion as well.)

If you're in stable condition and the embryo is small enough, it can be removed through a procedure called laparoscopic surgery. An ob-gyn can examine your tubes with a tiny camera inserted through a small cut in your navel and can often remove the embryo or remaining tissue while preserving your tube. (However, if there's extensive damage to the tube or you're bleeding profusely, the tube may need to be removed.)

Laparoscopic surgery requires general anesthesia, special equipment, and a surgeon experienced in the technique, and you'll need about a week to recuperate.

As with drug treatment, you'll need to get a series of blood tests after the surgery to monitor your hCG levels to make sure that removal of the ectopic pregnancy was complete. Again, this testing will continue until the levels reach zero, which usually takes a few weeks.

In some cases – for example, if you have extensive scar tissue in the abdomen or heavy bleeding, or the embryo is too large – laparoscopic technology may not be an option. If this is the case, you'll need major abdominal surgery.

You'll be given general anesthesia and an ob-gyn will open your abdomen and remove the embryo. (As with laparoscopic surgery, your tube may be preserved or may need to be removed, depending on the situation.)

Afterward, you'll need about six weeks to recuperate. You may feel bloated and have abdominal pain or discomfort as you heal.

Note: If your blood is Rh-negative, you'll need a shot of Rh immune globulin after being treated for an ectopic pregnancy (unless the baby's father is also Rh-negative).

Can I have a successful pregnancy after I've had an ectopic one?

Yes. The earlier you end an ectopic pregnancy, the less damage you'll have in that tube and the greater your chances will be of carrying another baby to term. And even if you do lose one of your tubes, you can still become pregnant without the help of fertility procedures as long as your other tube is normal.

However, if your first ectopic pregnancy was the result of damage to the tube from an infection, tubal ligation, or DES exposure, there's a greater chance that the other tube is damaged as well. This may reduce your chances of conceiving and increase your chances of another ectopic pregnancy.

If you're unable to conceive naturally because of damaged tubes, you're likely to be an excellent candidate for fertility treatments such as in vitro fertilization (IVF).

How can I deal with my sense of loss?

You may feel devastated by your experience. You've just lost a pregnancy, and it may now be more difficult for you to conceive again. You may also be recovering from major surgery, which can leave you exhausted and numb or suffering from hormonal ups and downs that may leave you feeling depressed and vulnerable.

You'll need time to recuperate emotionally and physically before trying to get pregnant again. Most caregivers will advise you to wait at least three months after major abdominal surgery for your body to heal. (Your risk of having another ectopic pregnancy is also higher while you're healing.) You may be eager to try again, or you may be frightened and wary.

Your partner may also be feeling sad or helpless and may have trouble figuring out how to express those feelings or how to be supportive. This experience may bring you closer together or it may strain your relationship. Consider getting some counseling if you think it will help you or your partner recover. (If you don't have someone in mind, ask your caregiver for a referral.)

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